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YOUR PERSONAL LIFE COACH AND COUNSELLOR

When your intentions are positive and you feel joy, you are in a beautiful place to attract and manifest all your heart wants."

- Branka B. Moore

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Client-Counsellor/Coach Consent To Remote (E-mail, Telephone, Skype) Treatment Form

All individuals who would like to participate in remote counselling with Imagineering Counselling Services (ICS™) and Branka B. Moore are required to review the Client-Counsellor/Coach Remote form and agree to the following conditions:

  • You understand that I practice in the province of Ontario Canada and am governed by the laws of this province.
  • You agree that you are at least 18 years old.
  • Imagineering Counselling Services and Branka B. Moore are not equipped for a crisis or emergency situation. ICS™ will not provide emergency care services of any kind.
  • You agree to supply your true full name, address, and phone number and e-mail address on the Remote Client–Counsellor/Coach Consent Response Form. You agree that all of the information you have provided is true and accurate, and that no important information has been deliberately omitted. You understand that if any of this information is inaccurate, this may be a major limitation in my ability to help you.
  • While I am hopeful that our work together will be helpful to you, Imagineering Counselling Services and Branka B. Moore cannot guarantee a positive outcome.
  • Imagineering Counselling Services and Branka B. Moore reserve the right to choose whether or not to work with you via remote. If, during our work together, I discover that you are not, in fact, someone who can benefit from remote counselling, I will discuss this with you immediately and will suggest that you seek out the services of a therapist in an office in your local area.
  • If you are currently taking medication for depression, anxiety, or any psychological or psychiatric problem, I may ask for your permission to contact your physician.

Imagineering Counselling Services and Branka B. Moore cannot be held responsible for remote services that are temporarily out of service. By filling out and returning the Imagineering Counselling Services Remote Client-Counsellor/Coach Consent Response Form, you indicate that you understand and agree to the terms and conditions stated below:

Confidentiality In General: As a counsellor in Ontario I protect the confidentiality of the communications and contacts with all clients, including remote clients. I will only release information about our work to others with your written permission, or if I am required to do so by a court order or legal subpoena.

Confidentiality Exceptions: According to Ontario law there are three situations where as your counsellor I am required to break the confidentiality that we work so hard to retain and call local law enforcement or social authorities.

  1. If during your sessions you give any information that would lead me to believe that you may hurt yourself, someone else, or someone may hurt you in any way, I will notify the appropriate authorities to prevent such actions from taking place.
  2. If during your sessions you give any information that would lead me to believe that there is neglect or abuse of a minor, I will notify the appropriate authorities to prevent such actions from taking place.
  3. If during your sessions you give any information that would lead me to believe that a regulated health professional has been involved with sexual abuse, I will notify the appropriate authorities to prevent such actions from taking place.

Phone Confidentiality: As your counsellor Branka will do everything possible to protect your identity and keep all confidences. However, it is at times not possible to guarantee 100% protection of the confidentiality of phone calls if you choose to use a cordless or cell phone during a phone session. At times it is possible for someone with a scanner to possibly hear the conversation. The goal of phone counselling is to help you. If at any time, either you or I feel that working together is not helpful enough to you, either is free to terminate the relationship.

There are no other explicit or implicit commitments to the counselling relationship.

 

 

Imagineering Counselling Services

Remote Counsellor/Coach Consent Response Form

By reading the Client-Counsellor/ Coach Consent To Remote Treatment and submitting this response form, you are stating you are at least 18 years old and you understand and agree to the terms and conditions set therein.

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